Clinical Decision Support ROI of Knowledge Management in Healthcare Services

1
Clinical Decision Support ROI of Knowledge
Managementin Healthcare Services

• Tonya Hongsermeier, MD, MBA
• Partners Healthcare Systems
• Corporate Manager
• Clinical Knowledge Management and Decision Support

2
Stats

• Today, with healthcare expenditures at 14 of
  GDP, Uncle Sam is paying half of the bill, this
  will grow with aging population
• Medicare, Medicaid and Military beneficiaries
• Today, there are 4 workers/Medicare beneficiary,
  by 2079, 21 ratio
• Numerous efforts to curb inflation
• Managed Care reduced resource consumption
  without patient safeguards
• DRG-based/case-based reimbursement Drive-by
  Bypass surgeries and Deliveries
• Capitation Capped suppliers without patient
  safeguards, Drs kept short hours in places
  without elevator access
• All Failed

3
Simplified US Healthcare System
CMS/TriCare/VA
Employers
Payors

• Goals
• Give consumers greater financial responsibility
• Reduce Hospitalizations and cost per
  hospitalization
• Increase quality performance (NCQA/JCAHO)
• Reduce drug expenditures
• Reduce imaging study expenditures
• Increase wellness/reduced sick days

Pharma
Hospitals
Doctors
Consumers
4
Employer initiatives now

• Leapfrog reduce unnecessary adverse events
• CPOE
• High Procedure Volume hospitals
• Intensivists on site
• HEDIS measures/JCAHO core measures Value-Based
  Purchasing
• Defined Contribution Consumer determines where
  to spend first 2000
• Consumerism cannot drive down the cost of
  services unless the value is transparent

5
Use Case ExamplesROI of CDS in Healthcare

• Safety and Primary Preventive Care in Inpatient
  and Outpatient Setting
• Disease Management and Secondary Prevention
  Diabetes, Geriatric Prescribing
• Roches challenge p450, a new diagnostic test

6
In the early 90s

• Little tangible business case for quality
• Increased errors ? increased resource consumption
  ? increased reimbursement for everyone except for
  DRG case-based reimbursment
• Selling CDS was impossible
• Then, the IOM report was published

7
Errors Cause Real Harm

• Medical Errors kill between 44,000 and 98,000
  people each year
• 7.3 of hospital admissions incur preventable
  medication errors
• 66 of these were not intercepted
• 25 resulted in patient harm
• 360 preventable Adverse Drug Events for a
  hospital with 20,000 annual admissions, almost 1
  ADE per day

8
Outpatient Adverse Drug Events

• Overall
• 25 of outpatients incurred an ADE
• 39 were preventable
• Antidepressants and antihypertensives were
  largest contributors
• Elderly (over 65)
• Adverse Events in 5 of population per year
• 28 preventable
• New benzodiazepine w/in 30 days doubles risk of
  hip fracture
• Cardiovascular agents, diuretics, non-opioid
  analgesics, hypoglycemics, anticoagulants were
  largest contributors
• Causing falls, strokes, bleeds, renal failure,
  dementia, etc

Gandhi et al, NEJM 2003348(16)1556-1564
Gurwitz et al, JAMA 20032891107-16
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NEJM Chances of Receiving Appropriate Preventive
Care is about 50
MAKING THE GRADE - Doctors in California were
graded using a weighted scorecard on the
following Childhood immunizations - Children
who turned 2 years old during the measurement
year who received both Chicken Pox and
Measles/Mumps/Rubella vaccinations
Breast-cancer screening - Women age 50 through
69 who had a mammogram Cervical-cancer
screening - Women age 18 through 64 who received
one or more Pap tests Asthma - Patients with
persistent asthma,in three age groups,who
received at least one dispensed prescription for
inhalers Coronary-artery disease - Patients age
18 through 75 with major heart conditions who
showed evidence of cholesterol screening
Diabetes - Patients with childhood and
adult-onset diabetes age 18 through 75 who had
evidence of blood-sugar screening Note The
above measures account for 50of the total
score.Other measures include patient experience
(40) and investment in technology (10).
10
Computer-Based Clinical Decision Support Evidence
Shows

• 55-83 decrease in hospital non-intercepted
  serious ADEs using CPOE
• 22-78 increased adherence to preventive health
  reminders
• At Partners, Drug-Drug Interaction checking
  intercepts 5 of physician orders, physicians
  change their decision about 33 of time

Kaushal R, et al. Arch Intern Med. 2003
Bates, JAMA 1998 And Unpublished
11
Hospital Business Case for Safety and Quality

• Preventable Adverse Drug Events add 4685 to an
  admission
• 1.7 million annual excess costs in a hospital
  with 20,000 annual admissions
• Sedation exceeding HCFA guidelines occurred in
  20 of elderly admissions, adding 5200 or 7.3
  days per case
• Failure to wean, falls, hip fractures
• 10.4 million annual excess costs for a hospital
  with 10,000 annual Medicare admissions
• Pressure Ulcers add 1900 to an admission, sites
  self-report rates of 5-10
• 1.9 to 3.8 million annual excess costs in a
  hospital with 20,000 annual admissions
• Nosocomial infections add 100s to 10,000s per
  case
• Numerous studies show sub-standard antibiotic
  prescribing practices in the hospital resulting
  in excess costs and mortality
• NEJM study of advanced antibiotic prescribing
  system showed reduction of 18,500/case where
  clinicians accepted advice of system vs cases
  where advice was ignored
• Failure to meet JCAHO core-measure goals will
  result in reduced reimbursement by CMS and Payors
  in coming years

12
Most common prescribing error is failure to
adjust for renal function
Renal Dosing Calculates Creatinine Clearance
First, Then Presents Calculated Default Dose
Its a 3000 x 4 cell decision table
13
Geratric Dosing Presents Adjusted Default Dose A
250-row Decision Table with Multiple
Substitution Recommendations
14
Employer/Payor business case for CDS - Diabetes

• Estimated avg 21,000/year per diabetic employee
  in absenteeism, disability and medical costs
  (study of 6 employers with 375,000 employees
• Glycemic control is associated with 1000-2000
  medical costs savings/year to payor
• Currently, we are reimbursed to measure HgA1c
  annually (captured claim for test ordered)
• Will soon be reimbursed for maintaining control
  through test result surveillance, goal is lt 7
• Smart Form about 300 rules

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Composite Decision Support Application Diabetes
Management
Guided Data Review
Guided Observation Capture
Guided Ordering
16

• Payor contracts withhold money annually to reward
  good HEDIS performance
• This can swing a physicians compensation by
  10-15K
• We are gathering data (unpublished) that shows
  that clinicians that use CDS do better than those
  that dont
• Physicians who are not wired will increasingly
  find themselves financially penalized

17
The Genetic Revolution Begins
Leading the News Roche Test Promises to Tailor
Drugs to Patients --- Precise Genetic Approach
Could Mean Major Changes In Development,
Treatment
June 25, 2003 Roche Holding AG is launching the
first gene test able to predict how a person will
react to a large range of commonly prescribed
medicines, one of the biggest forays yet into
tailoring drugs to a patient's genetic
makeup. The test is part of an emerging approach
to treatment that health experts expect could
lead to big changes in the way drugs are
developed, marketed and prescribed. For all of
the advances in medicine, doctors today determine
the best medicine and dose for an ailing patient
largely by trial and error. The fast-growing
field of "personalized" medicine hopes to remove
such risks and alter the pharmaceutical
industry's more one-size-fits-all approach in
making and selling drugs.
18
Cytochrome P450 Test

• No data on its value
• Worse, no knowledge base on how to use the test
  result
• No titration algorithms
• No substitution algorithms
• Test should be almost as cheap as a creatinine
  clearance

19
ROI is always on shifting sand

• Reimbursement policies always change based on
  public sentiment, employer/payor maneuvers, and
  government policies
• Suppliers are always trying to stay ahead of
  these policy shifts
• Aging, Obesity, Diabetes, CAD, Oncology and
  infectious diseases will continue to drive US
  inflation
• Expect new counter-measures if a magic bullet
  is discovered for type 2 DM and it still costs
  more than a life-time of current standard care.